Hyperammonemic Encephalopathy: valproic acid-induced adverse reaction

Introduction Hyperammonemic encephalopathy is an unusual but fatal consequence of patients being treated with valproic acid (VPA). The most relevant clinical features in cases of valproic acid-induced hyperammonemia include confusion, lethargy, vomiting, and increased seizure frequency and may progress to stupor, coma, and lead to death in isolated cases. The causes are not fully elucidated, but studies suggest alterations in liver and kidney function with abnormalities in the urea cycle causing increased ammonium levels. Objectives Clinical review and treatment approach for VPA-induced hyperammonemia encephalopathy. Methods Clinical case and literature review. Results A 23 - years - old male, admitted to the psychiatric unit for a psychotic episode in the context of drug use and associated affective symptoms. Treatment with antipsychotic (Risperidone 6mg per day) and mood stabilizer (valproic acid up to 1000/mg per day) was prescribed. After ten days of treatment, the patient started with low level of awareness and abnormal behaviour. Neurological examination showed marked somnolence, dysarthric language, unstable gait and behavioral alterations. In the physical examination the constants are stable with discrete tachycardia. Laboratory tests revealed hyperammonemia (609μg/dL), with normal liver function and serum concentration of total valproic acid was therapeutic (69mg/L). Brain computed tomography (CT) revealed no significant anomalies. Doctors initiated treatment with daily cleansing enema and VPA was suspended immediatly. After forty-eight hours the patient’s mental status gradually improved back to baseline and the ammonium levels were normalized in medical tests. Conclusions Valproate-induced hyperammonemic encephalopathy is an unusual but serious complication. It is often underdiagnosed, with an unclearly incidence. The consequences of undertreatment can be potentially deadly. Clinical suspicion should be established in all patients with decreased level of consciousness in patients receiving VPA. Hyperammonemia can be asymptomatic in half of the cases and can occur in people with normal therapeutic doses and normal serum valproate levels. The mechanism of VPA-induced hyperammonemic encephalopathy is unclear. At present, it is thought to be primarily due to propionic acid, a metabolite of VPA, which inhibits an enzyme necessary for the elimination of ammonia in the urea cycle. In addition, VPA can raise plasma ammonia levels through interaction with carnitine, leading to increased renal excretion of carnitine. In terms of treatment, the main recommendations agree that discontinuation of valproate is the most effective therapy, followed by administration of lactulose to reduce ammonium levels. Carnitine supplementation may be useful in the following cases: for seizure disorders in children at risk of developing carnitine deficiency, in VPA poisoning and in VPA-induced hepatotoxicity. Disclosure of Interest None Declared

Introduction: Eye Movement Desensitization and Reprocessing (EMDR) is a powerful psychotherapy approach developed by Francine Shapiro in 1987 when she realized that rhythmic eye movements reduce disturbing thoughts.The effectiveness of the therapy has been proven by many studies after its discovery.EMDR, which was initially used only in the treatment of Post Traumatic Stress Disorder, has become a treatment option used in the treatment of psychiatric disorders of more than 2 million people today.EMDR, which is used today, contains elements from many therapy schools andconsists of a phased protocol (Shapiro, 2018).Increasing evidence acknowledging the relationship between trauma and psychosis indicates that EMDR can be a vital addition to the treatment of psychosis (Sin & Spain, 2017;Valiente-Gomez et al., 2017).However, the effect of EMDR on psychosis has not yet been sufficiently clarified.There is alsoIt has not yet been clarified whether the curative effect on the psychotic symptoms or on the anxiety symptoms.For this reason, in our study, the effect of EMDR on these symptoms will be investigated by comparing the case and control groups.
Objectives: This study aims to evaluate the effect of EMDR therapy on post-traumatic stress symptoms, schizophrenia symptom severity and anxiety level in psychotic patients with at least one traumatic event.
Methods: This study is a randomized controlled, prospective follow-up study aiming to evaluate the effect of EMDR therapy on post-traumatic stress symptoms, schizophrenia symptom severity and anxiety level in psychotic patients with at least one traumatic event.Written informed consent to participate in the intervention study will be requested from all patients who meet the inclusion criteria.
Consent participants receive pre-treatment (T0) measurements.After T0, participants will be randomized to EMDR or waiting list Participants will be randomly assigned to 26 people in each group.These groups will be made by the independent randomization bureau of the Parnassia Institute of Psychiatry using the scientific randomization program on the Internet (www.randomizer.org).Results: The effects of EMDR therapy on posttraumatic stress symptoms, schizophrenia symptom severity and anxiety level in psychotic patients were obtained from pretest and posttest measurements.Conclusions: More studies are needed on the effectiveness of Eye Movement Desensitization and Reprocessing (EMDR) therapy.

EPV0937
Hyperammonemic Encephalopathy: valproic acidinduced adverse reaction E. Gómez*, L. Gallardo, R. Fernández, E. Talaya, L. Al Chaal and E. Rybak Introduction: Hyperammonemic encephalopathy is an unusual but fatal consequence of patients being treated with valproic acid (VPA).The most relevant clinical features in cases of valproic acidinduced hyperammonemia include confusion, lethargy, vomiting, and increased seizure frequency and may progress to stupor, coma, and lead to death in isolated cases.The causes are not fully elucidated, but studies suggest alterations in liver and kidney function with abnormalities in the urea cycle causing increased ammonium levels.Objectives: Clinical review and treatment approach for VPAinduced hyperammonemia encephalopathy.Methods: Clinical case and literature review.Results: A 23 -years -old male, admitted to the psychiatric unit for a psychotic episode in the context of drug use and associated affective symptoms.Treatment with antipsychotic (Risperidone 6mg per day) and mood stabilizer (valproic acid up to 1000/mg per day) was prescribed.After ten days of treatment, the patient started with low level of awareness and abnormal behaviour.Neurological examination showed marked somnolence, dysarthric language, unstable gait and behavioral alterations.In the physical examination the constants are stable with discrete tachycardia.Laboratory tests revealed hyperammonemia (609μg/dL), with normal liver function and serum concentration of total valproic acid was therapeutic (69mg/L).Brain computed tomography (CT) revealed no significant anomalies.Doctors initiated treatment with daily cleansing enema and VPA was suspended immediatly.After forty-eight hours the patient's mental status gradually improved back to baseline and the ammonium levels were normalized in medical tests.
Conclusions: Valproate-induced hyperammonemic encephalopathy is an unusual but serious complication.It is often underdiagnosed, with an unclearly incidence.The consequences of undertreatment can be potentially deadly.Clinical suspicion should be established in all patients with decreased level of consciousness in patients receiving VPA.Hyperammonemia can be asymptomatic in half of the cases and can occur in people with normal therapeutic doses and normal serum valproate levels.The mechanism of VPA-induced hyperammonemic encephalopathy is unclear.At present, it is thought to be primarily due to propionic acid, a metabolite of VPA, which inhibits an enzyme necessary for the elimination of ammonia in the urea cycle.In addition, VPA can raise plasma ammonia levels through interaction with carnitine, leading to increased renal excretion of carnitine.In terms of treatment, the main recommendations agree that discontinuation of valproate is the most effective therapy, followed by administration of lactulose to reduce ammonium levels.Carnitine supplementation may be useful in the following cases: for seizure disorders in children at risk of developing carnitine deficiency, in VPA poisoning and in VPA-induced hepatotoxicity.Introduction: Patients with schizophrenia tend to have high rates of suicidal ideation (SI), which consists of thoughts of selfdestruction, which increase the risk of self-extermination.Objectives: To determine the prevalence of SI and investigate associated factors in a sample of patients with schizophrenia.Methods: Descriptive and cross-sectional study, in which 49 patients with the condition were selected by convenience, treated at the Psychosis Outpatient Clinic of the Base Hospital of São José do Rio Preto/SP, between August/2021 and March/2022.The following were applied: 1) Sociodemographic Questionnaire, 2) Suicide Ideation Section of the Columbia Suicide Risk Assessment Scale (SISC-SSRS), 3) Suicide Risk Questionnaire from the Mini International Neuropsychiatric Interview (SRQ-MINI).Data were analyzed quantitatively (descriptive statistics and non-parametric tests; p<0.05).The study was approved by the local Research Ethics Committee.

Disclosure of
Results: The age of the participants ranged from 17 to 72 years (mean=45.8AE14.02), most were male (n=34;69.4%),had not completed elementary school (n=25; 51%), did not have a paid job (n=41; 83.7%) and had a family income of up to three minimum wages (n=23;46.9%).40.8% (n=20) reported at least one suicide attempt.According to the SISC-SSRS, in the last month: 22.9% (n=11) wished they were dead; 18.8% (n=9) thought about killing themselves; 12.5% (n=6) considered how they could perform the act; 10.4% (n=5) had intention and active planning; and 10.4 (n=5) persisted for the purpose of execution.The mean of affirmative answers was equal to 0.75 (AE1.55).In turn, in the SRQ-MINI, 79.6% (n=39) had a score indicating low risk for suicide, 18.4% (n=9) high risk and 2% (n=1) moderate risk.The overall mean was 5.77 (AE10.31),which indicates a moderate risk for suicide.There was a non-significant negative correlation between the risk of suicide and the factors of education (r= -0.20; p=0.15) and family income (r= -0.21; p=0.13).There was a significant positive correlation (r=0.81;p=0.0001) between the SISC-SSRS and SRQ-MINI, which indicates that despite the adapted use of the instrument, there is consistency and reliability in the results.Conclusions: The sample showed low rates of active SI and variation between low and moderate risk for suicide.SI should be asked to patients with schizophrenia, with a view to preventing suicidal behavior.

EPV0939 ADDICTION AND THE EVOLUTION AND COMPLIANCE OF SCHIZOPHRENIC PATIENTS
Introduction: Schizophrenia is a chronic illness, affecting approximately 1% of the general population.The more chronic a treatment is, the poorer the quality of adherence.In fact, approximately 60% of patients with schizophrenia are incompletely or non-adherent within one year of the first episode.Poor adherence has consequences in terms of clinical status, quality of life and psychosocial functioning due to associated relapses.One of the main factors of poor compliance is the use of addictive substances.Half of schizophrenic patients have, or have had, an addictive comorbidity during their life.Moreover, schizophrenic patients with addictive comorbidity have a more severe symptomatology and have more associated physical, psychological and social problems, representing a challenge in the management Objectives: The objective of our work is to evaluate the impact of addictive comorbidity on medication adherence and relapse.Methods: This is a cross-sectional study, carried out in patients with schizophrenia hospitalized or followed in ambulatory consultation, at the psychiatric hospital Ar-razi of Salé.The data collection (sociodemographic, clinical and therapeutic) is carried out by a questionnaire established for this purpose.The use of substances is evaluated according to the DSM-V criteria Results: A total of 110 schizophrenic patients were followed or hospitalized, of which 61.8% had a substance use disorder.The average age of onset of substance use was 18 years.The duration of substance use ranged from 1 to 11 years and up to 49 years for tobacco and cannabis.72% of the addicts tried to stop their use alone or in outpatient settings, only 17% in inpatient settings.The average duration of abstinence was 11 months and ranged from 1 to Interest: None Declared EPV0938 PREVALENCE OF SUICIDAL IDEATION IN PATIENTS WITH SCHIZOPHRENIA TREATED AT THE PSYCHIATRIC OUTPATIENT CLINIC OF A TEACHING HOSPITAL F. A. Borghi 1,2 *, L. C. Signorini 2 , L. Z. Alves 2 , R. C. C. Oliveira 2 and G. M. Araujo Filho 2